Maternal Near Miss in Patients with Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) may cause irreversible organ damage. Pregnancy with SLE may have severe life-threatening risks. The present study aimed to determine the prevalence of severe maternal morbidity (SMM) in patients with SLE and analyze the parameters that contributed to cases of greater severity.

Methods

This is a cross-sectional retrospective study from analysis of data retrieved from medical records of pregnant women with SLE treated at a University Hospital in Brazil. The pregnant women were divided in a control group without complications, a group with potentially life-threatening conditions (PLTC), and a group with maternal near miss (MNM).

Results

The maternal near miss rate was 112.9 per 1,000 live births. The majority of PLTC (83.9%) and MNM (92.9%) cases had preterm deliveries with statistically significant increased risk compared with the control group (p = 0.0042; odds ratio [OR]: 12.05; 95% confidence interval [CI]: 1.5–96.6 for the MNM group and p = 0.0001; OR: 4.84; 95%CI: 2.2–10.8 for the PLTC group). Severe maternal morbidity increases the risk of longer hospitalization (p < 0.0001; OR: 18.8; 95%CI: 7.0–50.6 and p < 0.0001; OR: 158.17; 95%CI: 17.6–1424,2 for the PLTC and MNM groups, respectively), newborns with low birthweight (p = 0.0006; OR: 3.67; 95%CI: 1.7–7.9 and p = 0.0009; OR: 17.68; 95%CI: 2–153.6) for the PLTC and MNM groups, respectively] as well as renal diseases (PLTC [8.9%; 33/56; p = 0.0069] and MNM [78.6%; 11/14; p = 0.0026]). Maternal near miss cases presented increased risk for neonatal death (p = 0.0128; OR: 38.4; 95%CI: 3.3–440.3]), and stillbirth and miscarriage (p = 0.0011; OR: 7.68; 95%CI: 2.2–26.3]).

Conclusion

Systemic lupus erythematosus was significantly associated with severe maternal morbidity, longer hospitalizations, and increased risk of poor obstetric and neonatal outcomes.

Keywords
maternal near miss; severe maternal morbidity; systemic lupus erythematosus; high risk pregnancy; potentially life-threatening conditions

Clinical criteria
Acute cyanosis	Loss of consciousness lasting 12 hours^e
Gasping^a	Loss of consciousness AND absence of pulse/heartbeat
Respiratory rate > 40 or < 6/min	Stroke^f
Shock^b	Uncontrollable fit/total paralysis^g
Oliguria nonresponsive to fluids or diuretics^c	Jaundice in the presence of pre-eclampsia^h
Clotting failure^d
Laboratory-based criteria
Oxygen saturation < 90% for ≥ 60 minutes	pH < 7.1
PaO2/FiO2 < 200mmHg	Lactate > 5
Creatinine ≥ 300 mmol/l or ≥ 3,5 mg/dl	Acute thrombocytopenia (< 50,000 platelets)
Bilirubin >100 µmol/l or > 6,0 mg/dl	Loss of consciousness AND the presence of glucose and ketoacids in urine
Management-based criteria
Use of continuous vasoactive drugsⁱ	Intubation and ventilation for 60 minutes not related to anesthesia
Hysterectomy following infection or hemorrhage	Dialysis for acute renal failure
Transfusion of ≥ 5 units red cell transfusion	Cardiopulmonary resuscitation (CPR)

Hemorrhagic disorders	Hypertensive disorders
Abruptio placenta	Severe pre-eclampsia
Accreta/increta/percreta placenta	Eclampsia
Ectopic pregnancy	Severe hypertension
Postpartum hemorrhage	Hypertensive encephalopathy
Ruptured uterus	HELLP syndrome
Other systemic disorders	Severe management indicators
Endometritis	Blood transfusion
Pulmonary edema	Central venous access
Respiratory failure	Hysterectomy
Seizures	ICU admission
Sepsis	Prolonged hospital stay (> 7 postpartum days)
Shock	Non anesthetic intubation
Thrombocytopenia < 100,000	Return to operating room
Thyroid crisis	Surgical intervention

Characteristics	Group			p-value	p-value
Characteristics	PLTC	MNM	Control Group	Control Group PLTC	Control Group MNM
Age (years old)
15 to 25	16 (28.6%)	9 (64.3%)	25 (31,6%)	0.2335^c	0.0647^a
26 to 35	34 (60.7%)	4 (28.6%)	38 (48,1%)
> 35	6 (10.7%)	1 (7.1%)	16 (20,3%)
(n)	56	14	79
Ethnic origin^d
White	34 (66.7%)	9 (75%)	37 (53.6%)	0.1507^c	0.1677^c
Other	17 (33.3%)	3 (25%)	32 (46.4%)
(n)	51	12	69
Education^e
None	6 (11.3%)	2 (18.2%)	9 (15%)	0.9241^c	0.9121^a
Primary school	14 (26.4%)	2 (18.2%)	17 (28.3%)
High school	28 (52.8%)	6 (54.5%)	29 (48.3%)
University	5 (9.4%)	1 (9.1%)	5 (8.3%)
(n)	53	11	60
Marital status^f
With partner	42 (79.2%)	9 (69.2%)	50 (69.4%)	0.2193^c	1.0000^b
No partner	11 (20.8%)	4 (30.8%)	22 (30.6%)
(n)	53	13	72
Number of pregnancies
1	25 (44.6%)	6 (42.9%)	24 (30.4%)	0.0895^c	0.3679^b
≥ 2	31 (55.4%)	8 (57.1%)	55 (69.6%)
(n)	56	14	79
Parity
0	29 (51.8%)	6 (42.9%)	31 (39.2%)	0.1484^c	0.7989^c
≥ 1	27 (48.2%)	8 (57.1%)	48 (60.8%)
(n)	56	14	79
Prenatal visits
0	8 (14.3%)	6 (42.9%)	15 (19%)	0.1638^a	0.0549 ^a
1–5	12 (21.4%)	4 (28.6%)	14 (17.7%)
6–12	25 (44.6%)	4 (28.6%)	41 (51.9%)
13–18	8 (14.3%)	0 (0%)	9 (11.4%)
> 18	3 (5.4%)	0 (0%)	0 (0%)
(n)	56	14	79

Patient	Age (years old)	Criteria
		Clinical	Laboratory	Management
Case 1	31	–	–	Hysterectomy following infection or hemorrhage
Case 2	28	Shock	–	Transfusion of ≥ 5 units of red cells
Case 3	25	Clotting failure	Lactate > 5 / Platelets < 50,000	Transfusion of ≥ 5 units of red cells
Case 4	20	–	–	Transfusion of ≥ 5 units of red cells
Case 5	24	Respiratory rate > 40 or < 6/min	Lactate > 5	–
Case 6	24	–	Oxygen saturation < 90% for ≥ 60 minutes/Lactate > 5	Intubation/ventilation for ≥ 60 min not related to anesthesia
Case 7	22	–	Creatinine ≥ 3.5mg/dl	Dialysis for acute renal failure
Case 8	32	–	Creatinine ≥ 3.5mg/dl	Dialysis for acute renal failure
Case 9	37	–	Creatinine ≥ 3.5mg/dl	Dialysis for acute renal failure
Case 10	25	–	Creatinine ≥ 3.5mg/dl	Dialysis for acute renal failure
Case 11	27	–	Creatinine ≥ 3.5mg/dl	–
Case 12	19	–	–	Dialysis for acute renal failure
Case 13	22	–	Creatinine ≥ 3.5mg/dl/ Lactate > 5	–
Case 14	22	–	Lactate > 5	–

Characteristics	Group		p-value	OR (95% CI)
Characteristics	PLTC	Control Group
Hospital Stay (days)			< 0.0001	18.8 [7.0–50.6]
< 8 (ref)	22 (39.3%)	73 (92.4%)
≥ 8	34 (60.7%)	6 (7.6%)
(n)	56	79
GA at delivery (weeks)			0.0001	4.84 [2.2–10.8]
< 37	47 (83.9%)	41 (51.9%)
≥ 37 (ref)	9 (16.1%)	38 (48.1%)
(n)	56	79
Outcome/Mode of delivery
Miscarriage	1 (1.9%)	12 (15.2%)	0.1301^a	5.78 [0.7–49.3]
Cesarean section	41 (74.5%)	40 (50.6%)	0.0774	0.47 [0.2–1.0]
Vaginal (ref)	13 (23.6%)	27 (34.2%)		–
(n)	55^b	79
Neonatal outcome
Neonatal death < 7 days	4 (7.5%)	0 (0%)	0.0975^a	12.84 [0.2–57.7]
Neonatal death ≥ 7 days	2 (3.8%)	0 (0%)	0.5275^a	7.13 [0.1–25843.3]
Miscarriage/stillbirth	3 (5.7%)	14 (18.2%)	0.1916	0.31 [0.083–1.1]
Hospital discharge (ref)	44 (83%)	63 (81.8%)		–
(n)	53	77
Birthweight (grams)
≤ 2,500	32 (59.3%)	19 (28.4%)	0.0006	3.67 [1.7–7.9]
> 2,500	22 (40.7%)	48 (71.6%)
(n)	54^c	67^d

Characteristics	Group		p-value	OR (95% CI)
Characteristics	MNM	Control Group
Hospital Stay (days)			< 0.0001	158.17 [17.6– 1424.2]
< 8 (ref)	1 (7.1%)	73 (92.4%)
≥ 8	13 (92.9%)	6 (7.6%)
(n)	14	79
GA at delivery (weeks)			0.0042	12.05 [1.5–96.6]
< 37	13 (92.9%)	41 (51.9%)
≥ 37 (ref)	1 (7.1%)	38 (48.1%)
(n)	14	79
Outcome/mode of delivery
Miscarriage	6 (42.9%)	12 (15.2%)	0.0899^a	0.22 [0.05–1.04]
Cesarean section	5 (35.7%)	40 (50.6%)	0.5687	0.89 [0.20–4.0]
Vaginal (ref)	3 (21.4%)	27 (34.2%)		–
(n)	14	79
Neonatal outcome
Neonatal death ≥ 7 days	2 (14.3%)	0 (0%)	0.0128^a	38.4 [3.3–440.3]
Miscarriage/stillbirth	8 (57.1%)	14 (18.2%)	0.0011	7,68 [2.2–26.3]
Hospital discharge (ref)	4 (28.6%)	63 (81.8%)
(n)	14	77
Birthweight (grams)
≤ 2,500	7 (87.5%)	19 (28.4%)	0.0009	17,68 [2–153.6]
> 2,500	1 (12.5%)	48 (71.6%)
(n)	8^b	67^c

	Group			p-value	p-value
Systemic impairment	PLTC	MNM	Control Group	Control Group PLTC	Control Group MNM
	n = 56	n = 14	n = 79	Control Group PLTC	Control Group MNM
Renal disorder	33 (58.9%)	11 (78.6%)	28 (35.4%)	0.0069	0.0026
Cutaneous disorder	36 (64.3%)	9 (64.3%)	65 (82.3%)	0.0177	0.1521 ^a
Arthritis	39 (69.6%)	9 (64.3%)	57 (72.2%)	0.7513	0.5385 ^a
Serositis	11 (19.6%)	2 (14.3%)	13 (16.5%)	0.6332	1.0000 ^a
Blood disorder	28 (50%)	10 (71.4%)	32 (40.5%)	0.2741	0.0321
Neurologic disorder	4 (7.1%)	3 (21.4%)	8 (10.1%)	0.7606^a	0.3619^a
Antibodies
Anti DNA	19 (33.9%)	3 (21.4%)	21 (26.6%)	0.3571	1.0000^a
Anti Smith (Sm)	10 (17.9%)	2 (14.3%)	15 (19%)	0.8677	1.0000 ^a
Anticardiolipin	11 (19.6%)	1 (7.1%)	6 (7.6%)	0.0376	1.0000 ^a
Lupus anticoagulant	4 (7.1%)	1 (7.1%)	0 (0%)	0.0278 ^a	0.1505 ^a
Anti Ro	15 (26.8%)	2 (14.3%)	27 (34.2%)	0.3607	0.2120 ^a
Anti La	4 (7.1%)	0 (0%)	5 (6.3%)	1.0000 ^a	1.0000 ^a
Antinuclear	47 (83.9%)	11 (78.6%)	62 (78.5%)	0.4291	1.0000 ^a
Anti RNP	14 (25%)	3 (21.4%)	20 (25.3%)	0.9667	1.0000 ^a

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